Pharma Virumque

Going around the psychiatry blogosphere recently: this segment by John Oliver about doctors who take pharmaceutical company money:

I will resist the urge to geek out about its minor medical errors1 in favor of clarifying something more important.

The impression you’re supposed to get from this piece is a shady looking man handing you a briefcase full of cash and whispering “Hey, here’s $10,000 for you if you prescribe unnecessary medication.” The implication is the doctors who do this are awful and if you were in medicine you would have no trouble resisting this temptation.

In reality, pharma companies have figured out that some people have ethical qualms – “evil cannot possibly understand good” only works in movies – and adjusted their strategies accordingly.

We’ll start with a simple one. Imagine you’re a doctor, and your staff are complaining because the staff at every other doctor’s office has been getting these incredible free lunches every day – the video says drug companies aren’t supposed to give, like, Zagat-rated steakhouse lunches, but there’s still a lot of room between “Zagat-rated” and “Way better than the peanut butter and jelly sandwich you bring from home”. The nurses are grumbling and threatening to revolt and asking if you really appreciate them.

A drug company representative offers to provide your office with free lunches a couple of times a week.

You say “It would be really annoying to actually use the phrase ‘there’s no such thing as a free lunch’ here, so I will just ask what the catch is.”

They say “No catch. We don’t require you to ever prescribe any of our drugs. We don’t require you to listen to our presentation. We don’t even require you to read our promotional literature. Just accept our offer.”

You say “Why are you doing this?”

They say “Because every time you eat one of our lunches, you’ll associate the ice cold taste of Coca-Cola and the sweet warm chewy chocolate chip cookies with our company, and you’ll get positive feelings about it, and maybe those positive feelings will influence your prescription habits.”

You say “I think I’m a good enough doctor not to prescribe a drug solely because I get lunch from their company.”

They say “Look. We all know that most antidepressants are about equally effective. Sure, we split hairs and talk about how one has more anticholinergic side effects so it’s bad for patients with cholinergic sensitivity, and another has more chance of weird visual disturbances, but how often does someone come into your office and announce ‘Hey, I’m depressed, and also I have cholinergic sensitivity, but I LOVE weird visual disturbances!’? Although there are a few cases where one drug’s clearly a better choice than another, most of the time you’re about equally balanced between two or three options, and you just pick one at random. So maybe instead of picking one at random, you’ll pick the one you associate with delicious food. And if you do, so what? Nobody’s harmed. You would have just flipped a coin anyway.”

You say “I’d rather flip a coin than feel like I’m being pressured by what I had for lunch.”

They say “Look, you secretly worry anyway that you sometimes prescribe Effexor because the name makes it sound effective, or Paxil because the name makes it sound peaceful.”

You say “Wait, you can read my thoughts?”

They say “We’re a pharmaceutical company. Of course we can read your thoughts. Look. You already know that the mostly-meaningless choice of which of several equally effective drugs you prescribe is influenced by a bunch of silly marketing factors beyond your control. Why not add one more?”

“But -”

“Come to the Dark Side! We literally have cookies!”

Still not tempting enough for you?

Okay, imagine this. You’re a doctor and one of your patients comes in with incurable chronic pain that’s ruining their life. You try the normal medications on it and nothing works very well. There’s a high-tech next-generation medication available that you think is a good fit for your patient’s disease, but it’s not covered by their insurance and there’s no way the patient can afford it. You have to tell this guy that there’s nothing you can do for him.

Then a drug company representative comes to you bearing a big box of free samples. By “free samples” I mean hundreds of pills, enough to help the patient for the better part of a year – and maybe at the end of that time you’ll get another box of free samples. The drug rep doesn’t want you to sign your life away. She’s giving them for free, no obligation, maybe just listen to a sixty second speech on how to prescribe them safely and effectively (she wouldn’t want to give them to someone who won’t prescribe them effectively!) Are you really so fundamentalist in your approach to medical ethics that you won’t listen to a drug rep for sixty seconds in order to save a patient’s quality of life?

Most doctors – even the ethical ones who would refuse the briefcase full of cash – take the offer. This practice has come under increasing scrutiny recently. Some of the complaints are kind of dumb, but one very valid one is that a lot of the times what happens is you start off by giving the patient 100 days of free sample or something, then the free sample runs out, they’re fixated on that particular medication because it’s the one that worked for them, and they find some costly way to continue the (more expensive new) medication – instead of the two of you working harder to find some older less expensive medication that works equally well. A few drug companies have “fixed” this by giving out cards for “prescription programs” that solve some of the problems with free samples. These are even harder to resist, and they’re also given out by attractive drug reps who just want to tell you a few important facts about the drug before giving it to you.

Still not tempting enough for you?

Fine, then imagine this. You’re a doctor who really believes in a particular drug and is trying to convince the medical community to use more of it. For example, a couple weeks ago I wrote an article on suboxone saying it was one of the best medications for opiate abuse and I wish the medical community would pay more attention and prescribe it more often.

I wrote that article for free as a public service because I think that drug saves lives. But imagine that the company that makes suboxone approached me afterwards and said “Hey, you seem to have an important message to spread. Why don’t we sponsor you to go around the country for a week or two telling it to other doctors at medical conferences? We’ll get you first-class flights, put you up in five-star hotels, and give you a $10,000 stipend.”

I say “Wait a second, that sounds like taking pharmaceutical company money, and taking pharmaceutical company money is evil.”

They say “Look. You were trying to promote suboxone to people already. You were just doing a bad job because you were limited to one little blog. The more suboxone-promoting you do, the more doctors know about this drug – which you yourself have said is life-saving – and so the more lives get saved. If you’re willing to promote suboxone ineffectively for free, why not promote suboxone effectively for $10,000 plus nice hotels?”

I say “I’m still kind of uncomfortable with this.”

They say “Okay, well, it’s not our fault if hundreds of people die of drug overdoses because their doctors didn’t know suboxone was an option.”

You’re probably going to ask if I’ve ever accepted any of these offers. The boring truth is that I haven’t had to consider them because I’m a resident and residents are lower than dirt and the pharmaceutical companies know this and they don’t waste time trying to cozy up to us.

I have tasted the forbidden fruit only once, and it was my attending’s fault. She told us that there was a big dinner being planned for the entire psychiatric community of our city. The goal was to get doctors to meet nurses to meet therapists to meet social workers in one place so we could all get to know each other and talk about changes we could make to the system. It was very important that we attend, or else the nurses and therapists and social workers would think that the doctors were too snooty to interact with them and didn’t care about changing the system. Oh, and by the way the dinner was sponsored by PANEXA (here used in place of the real drug because I don’t want to get in trouble for calling them out) but there wouldn’t be any promotional material or pressure to prescribe PANEXA, honest, no sirree.

This was a tempting offer precisely because it was such a good idea. Everyone in the local psychiatric community deals with each other frequently, but we’d mostly never met before. I know them as the voice on the other side of the phone saying “No, no beds are available in our facility” or as the person who refuses to fax me my patient’s past medical history because the patient is too catatonic to sign a consent form. None of us are ever entirely sure what the others are doing, sometimes there are bad feelings, and it was reasonable to hope that maybe if we all met each other and socialized things would get a little smoother.

So we all meet at this restaurant, and immediately World War III breaks out. It’s like “Hi, I’m Mary, the clerk at Blue Sky Mental Health.” “MARY?! YOU’RE THE ONE WHO DIDN’T FAX ME THOSE RECORDS I NEEDED TWO MONTHS AGO! MY PATIENT WENT A WEEK ON THE WRONG DRUGS BECAUSE OF THAT!”

“Hi, I’m Dr. Alexander, I work at the inpatient unit in Our Lady Of An Undisclosed Location Hospital…” “WE HAD A PATIENT COME FROM THERE TWO WEEKS AGO AND HE ASSAULTED A STAFF MEMBER. IF YOU’RE A REAL HOSPITAL WHY CAN’T YOU DO PROPER VIOLENCE ASSESSMENTS?”

It turned out that the nurses hated the social workers for making them wait on the phone forever in order to get a straight answer. The social workers hated the nurses for always calling them up when they were busy about things and expecting an answer RIGHT NOW. The social workers hated the doctors for giving patients one measly prescription, then handing the case over to them to fix all of the impossible problems in the patient’s life. The doctors hated the social workers, because when we give patients one measly prescription and then hand the case over to the social workers to fix all of the patient’s impossible problems, sometimes the impossible problems don’t get fixed.

Anyway, in the midst of all of this, there was one guy who was staying completely calm, talking nicely to everybody, helping people see each other’s sides of the issue, just a really serene well-adjusted guy. I escaped over to his table and asked him who he was and why he was here.

“Oh,” he said “I’m a paranoid schizophrenic currently on PANEXA.”

Of course he was.

Then we all broke off into our own groups and got some incredible Italian food.2

What I’m saying is, pharmaceutical companies are sneaky.

Footnotes

1: By which I mean “succumb to the urge to geek out about its minor medical errors, but in the footnotes”.

The video says that a “horrifying example” of pharmaceutical company overreach was how AstraZeneca took Seroquel, “an antipsychotic with dangerous side effects” and marketed it to doctors for depression, sleep, and dementia, adding “You can’t just give people dangerous drugs and see what happens!”

But actually, lots of studies have shown Seroquel is effective for depression, lots of guidelines suggest Seroquel as a backup depression treatment, and doctors have been (correctly) prescribing it for such for a long time. Doctors also very commonly prescribe it for sleep and dementia; I think is less evidence-based, but it’d be a lie to say it wasn’t common as dirt or that it didn’t work for these things (safety is the problem).

So what was happening was that AstraZeneca was promoting Seroquel for the things it was actually being used for, as opposed to the thing the FDA said it was supposed to be used for. Doctors are allowed to use drugs for whatever they want based on their own analysis and their best judgment, but pharmaceutical companies are only allowed to promote it for the FDA-approved indication, which at that point was psychosis and bipolar depression.

The reason the FDA hadn’t approved Seroquel for depression wasn’t because it was a bad idea. It was because in order to get the FDA to approve anything for anything, you must perform the appropriate ritual of putting a zillion dollars into a big pile, then burning it as a sacrifice to the Bureaucracy Gods. AstraZeneca had performed the ritual for bipolar and psychosis, but was still in the process of performing it a third time for depression. Once they finished, the FDA approved it as an adjunctive medication for depression, but also fined them hundreds of millions of dollars because they had advertised it for depression – merely based on evidence and clinical practice – before the FDA had told them they were allowed to.

This is still not the whole story, because best clinical practice says to only use Seroquel as a third- or fourth-line antidepressant after some others have failed, and in conjunction with another medication. If AstraZeneca was advocating to use it for depression first-line on its own, this would have been a genuine overstep and something to get upset about.

(research and clinical practice say to use it for sleep and dementia approximately never, but there is enough wiggle room in that “approximately” for doctors to drive a bus through, and they do.)

This is still not the whole story, because The Last Psychiatrist thinks the way the FDA’s handled the Seroquel indication, and the subsequent culture of prescribing that grew up based on that indication, is stupid.

The other minor medical error in the video is much simpler. Oliver mocks Wellbutrin’s claim to be “the happy, healthy skinny drug” saying that “the only happy, healthy, skinny drug is amphetamine”. But Wellbutrin is actually amphetamine-based – its full chemical name is 3-chloro-N-tert-butyl-β-ketoamphetamine – and it shares a mechanism of action with amphetamines, which is why some of its effects are similar as well. So Oliver’s joke was a lot more accurate and a lot less funny then he thought.

2: Then later, and contrary to the promises I received, they gave us a presentation on PANEXA anyway.

The schizophrenic guy worked for one of the local psychiatric community services groups doing community outreach. I never did figure out whether he was there as a coincidence or whether the pharmaceutical company had arranged to have him there. I suspect the latter but I have no proof.

In a famous speech in 1935, Stalin declared, “Life has gotten better, comrades. Life has become more joyful.”

High Party officials from Moscow were inspecting a psychiatric hospital somewhere in the provinces. As they walked into a ward, all the patients rose and chanted: “Life has gotten better. Life has become more joyful.”

The officials were pleased that the slogan had reached so far but noticed that one little fellow standing in a corner hadn’t joined in. “Why,” they asked him, “didn’t you say, ‘Life has gotten better?'”
“Excuse me, I’m not crazy, I just work here.”

Yep, that’s it. My attempts at Googling only yielded an “updated” version where the speaker is instead extolling the virtues of Obamacare. With that as my reference point, the joke’s true provenance is both interesting and totally unsurprising.

I’m in a similar situation, actually. I’m a financial advisor, and there’s a lot of money in it. At my company, we have 3 different insurance providers on our shelf, offering broadly similar products. Once a month or so we get a free lunch from one or another of them, talking about their latest product changes. Just last week, I got free pizza to listen to a presentation from(call them) Some Life Co. Seems Some Life had just changed around their term life policies to drop their price and add a couple new available riders, so they wanted to make sure we all knew about the new features and the fact that they(finally) weren’t completely terrible compared to the other two.

It was explicitly a sales lunch, of course, but they sell us on “This is a great feature for clients that look like X, and we now have the best prices on people from ages 40-65 in the industry”, which are of course really important things to know when it comes time to pick the right product for your clients. It’s never struck me as sleazy, though perhaps it’s a bit fatalistic to say “Well you’re used to pizza from the others so we’ll give you pizza too”.

But exactly because of that, in the end, it all cancels out. Some Life gives a presentation this month, Other Life gives one next month, and Third Life the month after, and they all buy us lunch. Sometimes our office puts on conferences that are literally sponsored by all three at once, and they all give their own presentation. Why would I send a client to Some Life because of a presentation or a pizza, if Other Life and Third Life are just as vocal in pointing out the virtues of their products? (I might give a policy to a company because of an excellent sales rep, in more complex and larger cases where I need to work closely with the rep to make the policy happen. But then our reps are all 50 year old industry experts, not perky 22 year olds, so it doesn’t seem nearly so sleazy).

“The other thing to note is that, in the end, it all cancels out.”
Well the argument would be that, sure, you aren’t favoring any one company, but you are going to be hugely biases towards giving some life insurance, and perhaps then to some people who it might make more sense not to have any at all.

Now, maybe you’d say that, actually everyone needs some life insurance, and you thought that beforehand or you wouldn’t be with a financial planning agency, in the same way that Scott has always thought that these cases should turn to medicine first if some is remotely feasible or whatever, and I believe you, but it’s the kind of thing that raises suspicion. The people who rail against Big Pharma aren’t mollified to find out that drug company A has no edge over drug company B, especially when they think exotic plant root could do the same thing but is being suppressed by the Big Pharma cartel.

I will say that the presentations we get are much more about “Here’s why you should buy from us and not those other guys” – selling us on the concept of insurance is mostly a matter of our disposition(I was a huge believer in it even when I thought I was going to be a physicist, though obviously I didn’t understand it as well, and anecdotally a lot of the other guys feel the same), with the company we actually work for also doing some work there.

But you’re right, this won’t mollify people who want to smash the system entirely.

At my place of work. we get pension and insurance companies coming in to give presentations about why we should invest in their plan, but we don’t get any freebies, not even free pens, let alone free lunches 🙁

Also, as public servants/civil servants, we’re not allowed take inducements or benefits-in-kind from suppliers, etc. so eight years back when I was working on multi-million pound new schools building and equipping project, myself and the other clerical officer involved wondered (jokingly) if we’d have to report ourselves for getting a Christmas present of two bottles of wine – between us, not each, and not expensive wine either) from one of our suppliers who’d gotten a couple of hundred thousands’ worth of business out of us.

I say stuff your face with free pizza if they’re making you sit through presentations on “Our plans are better than their plans” 🙂

How much does it matter that it all cancels out? Sure, you might be unbiased towards the prescriptions, but each drug company is still more likely to sell their product if they advertise to you, and you’re not the one paying the increased costs advertising incurs.

A big part of the advertising cost is free drugs, though – those actually only cost the companies pennies, because their marginal cost is quite low, but for legal reasons they need to consider them a marketing expense at their full retail cost. As such, accounting rules dramatically overstate real pharma advertising spending.

This is a good thing to know. The thing that I got out of the video is “wait, pharmaceutical companies spend 9 times as much on marketing as they do on research? For a bunch of drugs that are all pretty much the same, and in order to counteract all the other companies spending obscene amounts of money to promote their identical drug? This seems like a coordination failure.”

I hate this claim, because it’s patently false, and unhelpful. My experience has been with NSAIDS. They’re “pretty much all the same”, which means that in large tests, they’re all about equally effective, and have similar side-effect profiles. Except that they’re not. Ibuprofen works really well for me, for pain and inflammation and fever, with basically no side effects. Aspirin works for fever, with no side effects. Naproxen and Reloxafen don’t work very well for pain, and upset my stomach a lot. Other people have different experiences. The sort of people who complain about “me-too drugs” would leave us all taking just aspirin, or maybe aspirin and Naproxen, screwing over those of us who respond better to those “pretty much the same” drugs.

It seems to me that for a producer, advertising/distribution costs have to factor into their decision – in the long run, they won’t sell products where the total revenue is less than the total cost, right? As to whether direct marketing to physicians factors into marginal costs, I guess the question is whether the marketing results in marginal sales.

At the most reduced form, marketing works off an elasticity of advertising; how many more sales do you get spending another dollar on advertising. You can then compare this to the price elasticity of your product (how many more sales do you get by lower the cost of your produce by a dollar) and find the optimal strategies.

So if we look at a basic supply/demand chart, spending money on advertising shifts the Demand Curve out as you effectively create more demand… but if you’re spending money on advertising, you’re effectively driving up the cost to produce your product, which shifts the Supply Curve in.

An alternative way of thinking about it is that you can either spend money on advertising to increase demand or on efficiency to drive down costs. Assuming price stickiness to make the comparison easier, you could either sell your product to more people or make more money off each sale.

In a non-sticky world you can drop the price of your product and sell to more people (efficiency) or just sell to more people (advertising) and you’d go with whichever made you more money.

Jos, yes, it would affect long-run decisions. It might affect the decision of whether to bring a drug to market or not. But that is not the topic at hand.

Your conclusion is wrong. Advertising has no effect on the marginal cost of the supply curve. If advertising from both sides canceled out and had no effect on the demand curve, then the optimal price would not change between the alternatives of the both sides advertising or both sides not.

If you do not make that assumption, or if you consider more possibilities, then the situation is more complicated. In particular, yes, one assumes that marginal advertising produces marginal sales. But this is holding fixed the opposition’s advertising, and not relevant to the hypothetical. I would describe this as advertising moving the demand curve, but it is somewhat arbitrary how one labels it.

Douglas, your analysis is insufficient and comes to the wrong conclusion.

The drug industry is not in perfect competition. We can see this from first principles because there are extremely high startup costs (on a per-drug basis), etc. Also, the existence of patents is on its face proof of that the drug industry has monopolistic competition (or oligopoly depending on the type of drug).

We can also see that it’s not perfect competition just by observing that advertising exists and is a large fraction of expenditures. If the market were perfectly competitive advertising wouldn’t exist at all, or would be negligible.

If advertising suddenly vanished that would increase the rate of profit on drugs, which would attract more investors, which would either reduce the price of drugs (if the newly-invented drugs are competitors with existing drugs) or increase the number of treatable conditions (if the newly-invented drugs cover previously untreated conditions).

If the lack of advertising reduced economy-wide demand for drugs as a class, then that effect would mitigate the above. But if it doesn’t reduce economy-wide demand, there is a huge free lunch to be gained.

I did. Capital costs are a critical part of the cost of production, (NOT the marginal cost) and combined with the shape of the demand curve dominate actual pricing decisions. Marginal cost has a comparatively small effect on price.

“Also, the existence of patents is on its face proof of that the drug industry has monopolistic competition (or oligopoly depending on the type of drug).”

Not exactly. One can model the pharma industry as having various drugs that companies can “bid” on by researching, and thus the companies will bid up the price of researching drugs until profits match costs. There may be empirical evidence arguing against that model, but one cannot a priori reject it.

Phooey – if anyone in the future is reading this and has ideas on what I can read about how marketing costs factor into costs of production and the supply-demand model, I’d really appreciate it. I’ll probably keep checking this off and on for a few years.

I’m going to have to pull out my IO book tonight, but advertising kind of both is for creating demand and winning competition while also being quite wasteful.

In effect, advertising does create demand for the product category as a whole. But there comes a point where spending more money on advertising is inefficient compared to spending it elsewhere, such as dropping the price or investing the capital.

However, companies tend to spend more than is efficient because there is a brand component to your marketing. If Coke and Pepsi are both putting up ads, it’s going to drive demand for soda in general (which ends up with a free rider effect as well). However, if Pepsi goes the extra mile with advertising, they’re not going to create much more demand, but they’re going to shift the demand to Pepsi over Coke. So Coke also goes the extra mile and you end up spending a lot of money to end up with the same result as if nobody had blown the budget with ads. Granted, this is in a two party system; brand advertising does help take care of free riders, but the effect is so small that Pepsi and Coke would probably be better off just going in together on a “Soda: New York Hates It!” campaign.

Advertising to create demand has, like many other economic activities, diminishing marginal returns. When sugar sodas were invented, and nobody was advertising them, advertising definitely increased demand. The more money spent on advertising, the more demand there was for sugar sodas, up to a point. Eventually, there was so much advertising for sugar sodas that the maximum demand had been reached, and further advertising merely shifted consumers’ preferences.

Based on the ads I hear, I suspect most advertised products are at the fully saturated demand level, as most ads (like cars and sodas) are trying to promote their brand’s superiority. However, some products (and services) are not – the example that comes to mind right now is rooftop solar, where the ads are mostly selling you on the concept, as a substitute for The Power Company. (Though there’s still a bunch of brand differentiation in the advertising, based mostly on the financing.)

It reminds me of how people always say stuff like “OMG, they’re getting paid by the Kochs to say that!”. It seems more likely that the these “evil corporations” found someone who already shared their beliefs than bribing someone to say anything they want.

Well, the flip side of bribery is simply unfair signal boosting. Some academic being able to get their message out because they agree with some rich person is only as correlated with truth as the rich person’s opinion, and thus largely devalues the academic’s use as an expert.

On the other hand, rich people signal-boosting is probably inclined toward unpopular signals (why go to all the hassle of seeking out experts and setting up non-profits if every other newspaper editorial is already espousing your view anyway), so rich people boosting particular academic views should lead to more diversity of views.

And having to defend a popular view against a boosted unpopular view generally improves the experts’ understanding of their own popular view and keeps them on their toes. And hey, you never know, it may work out that the unpopular view is better.

So, while it may be unfair, it’s the sort of unfairness that generally makes everyone better off. (Note, I think the problem with climate change policy is not the deniers but that very few people actually are willing to undergo the massive lifestyle disruptions to stop it and there’s one hell of a collective action problem).

Tracy W – And yet, we can solve roughly 40% of the problem without any significant lifestyle disruption to most people . . . if we replace coal-generated electricity with nuclear power.

Which makes the actual single biggest barrier to at least major mitigation of climate change the organized opposition to nuclear power. Which is to say, groups like Greenpeace, WWF, and the Sierra Club.

One possible drawback could be that, next time you write a totally honest and well-research blog post about the virtues of Vaxadril, people will dismiss it out of hand by saying, “of course he’d say Vaxadril is great, he took a bunch of VaxaCo’s money just last month”.

I’ve spoken for a pharma company before as an MD and plan to do so again. I was willing to do so because it was a drug that I had been interested in long before it was approved (it still hasn’t been approved in the US; the previous speech couldn’t reference the drug directly for that reason but instead talked about different ways a particular physiologic goal could be achieved and was given back when they expected it to be approved).

It’s a unique drug. Nothing else is available that solves exactly the problems it does. It enhances patient safety while getting around some problematic side-effects of the drugs currently used to approximate its function. Why not advocate for it? Someone is going to take their money to promote it, might as well be me.

Explanation would be tedious, but the very short version is that drugs used to reverse residual paralysis at the end of anesthesia are indirect-acting and can still leave patients weak. They also contribute to nausea after surgery.

This works by chemically binding to the paralytic drugs in the bloodstream, immediately and completely reversing the paralysis. An elegant mechanism, and useful in airway emergencies.

I have to get my head out of the gutter. Until I looked up the drug online, I assumed that you were refusing to answer Anonymous’s question by giving the name of a fictional drug that sounds like “Suck my dick” when pronounced out loud.

I wonder if they should give it a different name when they distribute it.

The trade name in Europe is Bridion. No idea what they plan to use in the US if/when it is approved.

The name arises because it is a thioether (sulfur-containing) derivative of a gamma-cyclodextrin. Sulfur-gamma-dextrin -> sugammadex.

It is effective against aminosteroid paralytics, most especially rocuronium (trade name Zemuron), which is another interesting study in naming. “Cur” because it is a paralytic mimicing part of the structure of curare, “ron” because it uses a steroid body for its synthesis (e.g., testosteRONe = testicular steroid hormone), “nium” for the quaternary amino group (derived from the ammoNIUM ion, NH4+).

And the “ro”? Stands for “rapid onset”.

(For contrast, atracurium is another paralytic – though I don’t know what the “atra” stands for, you can tell it’s a paralytic from “cur” and a quaternary amine from “ium” – because quaternary amines are always ionized in the body, they cannot cross the blood-brain barrier without a specific cellular transporter, and there is no specific cellular transporter for curare derivatives.)

My undergrad degree is in chemistry. In retrospect, it utterly shocks me that I was in my fourth year of medical school before I realized I would absolutely love being an anesthesiologist.

It sounds dark because it sounds like “Doctor Bob doesn’t bother reading the literature to find out if Wundadrug really works or if makes its users turn purple and grow a third eye, he just prescribes it because Wundadrug Maker Inc sends out a blonde 22 year old in a slinky suit to slip him free samples and wine and dine him in high-class restaurants!”

Which is not at all the case – well, maybe some companies somewhere send out good-looking blonds/blondes to wine and dine potential clients at great expense, but if every pharmaceutical company is sending their rep round with a bag full of free samples and fliers on “New Amazo – even better than the three other similar brands because it avoids that inconvenient turning purple side-effect”, then most doctors will have a quick flip through the bumf to see if it really will turn their patient purple, then try the free samples out, and if patient Smith says “This is really great, doc! I feel like eating broccoli for the first time in years!”, then they’ll probably prescribe Amazo – until the next, even better, more improved drug comes out.

Novartis seems to have a history of generally shady behavior, and their guest speaker program here is at least alleged to have involved a lot of targeted internal policies being intentionally and repeatedly overlooked. They’re not alone on that, but it’s interesting that Glover mentions them more as a standard behavior.

On the other hand, the core of the system seems built to make it really easy to do broadly questionable stuff, while prohibiting things like sharing information.

This is still not the whole story, because The Last Psychiatrist thinks the way the FDA’s handled the Seroquel indication, and the subsequent culture of prescribing that grew up based on that indication, is stupid.

This … uh, as a patient, utterly horrifying is an understatement, and mind-boggling as a footnote to a story where the next closest terrible activity is someone taking money to shill a drug they’d shill for free. Even as someone not terribly happy about the FDA to start with, baseless class-of-drug wide warnings and increasing dosage in the interest of safety(!?) are ugly even by the normal standards of sausage-making.

I grew up in the 90s and my friends Dad was a rep for Pfizer. Back then I think you could do a lot more. He would take doctors on weekend long fishing trips. When “Twister” came out he rented out the local theater for Doctors and their families. He was always brining home huge expensive seafood platters form fancy dinners. We loved it!! I never even thought about it being unethical.

This is indeed a great story, but I think your second example cuts to the heart of it.

Oliver’s segment, for all its virtue, portrays the doctors as making the decision to prescribe on a whim or otherwise not accountable to anything but their own knowledge. When in fact, there is a person suffering right before them who is as often as not *demanding* a miracle cure, and the emotional pressure to give anything at hand must be enormous. I’m sure a lot of the training psychiatrists receive is precisely to resist this pressure, but no one’s made of stone. A company taking advantage of that emotional dynamic can make a lot of money.

The 100 days of free samples sounds horrible. Basically exactly in line with “first hits free”.

Not all drugs need to be taken long-term (though maybe most psychiatric drugs do?). E.g., I don’t live in the US, but I once had strep while visiting there and the doctor I saw gave me 10 days’ worth of antibiotics that he got as free samples.

Same here. It was free, solved the problem, and saved a trip to the pharmacy. If it builds goodwill for the company that gave the sample, so what? They objectively made my life better by giving free samples – goodwill is deserved.

Speaking as a patient, the fact that I was able to try out a variety of psychiatric drugs for free was pretty great. Some of them (including Seroquel, incidentally) were obviously showing side effects within a week, and I’d have been pretty pissed if I had to pay for a full month every time I got a non-starter. While my experience is obviously not universal, I can say those free samples were a major benefit to me.

One plus of free samples is that your patients can try them. Ages ago, I saw my doc for some depression around my divorce, and she gave me a couple packs of something or other to see if they helped my syptoms/caused side effects. (Around that time I started dating and stopped being depressed, so I never got a prescription. I guess if the drugs helped, then good job!)

The free samples are a GODSEND. My insurance decided that they weren’t goign to pay for my medication because of reasons. The next step here would be for the doctor to prescribe a less effective medication that the insurance would cover, or to prescribe a generic that I might be able to pay out of pocket. A third option would have been to enter the county mental health system. As it was, he handed me a few blister packs of samples, and I was saved. I don’t recall a hundred day limit, either. Generally you’re locked into your insurance for a year, so if the samples can get you to the end of the year you’re golden.

The thing that didn’t get brought up that bothers me the most is that the drug coupons basically amount to price fixing. If one person has excellent insurance to cover almost all of this incredibly expensive medication then great, but if they’ve got a huge copay then run this coupon through to take up to $200 off their copay. Meanwhile the insurance company is still paying full price. This allows drug companies to charge a much higher price for their patented medications than they would be able to otherwise; they’re able to tailor their prices to each individual.

This is one of many cases where the brokenness of the US health “insurance” model bleeds out into reality.

With an insurance company paying the bills while the patient reaps the benefits, cost and benefit become decoupled, and the incentive for drug seller and patient to exploit the insurance company together is large.

If the alternative to the status quo is “Company has to raise the price for everybody, because the non-couponers aren’t subsidizing the coupons anymore” or “company stops making the drug because they can’t turn a profit on it”, then the status quo seems superior.

If there is insufficient redistribution to poor, sick people to cover expensive therapies or insufficient health care spending in general, there are better ways to alleviate it without handing over a pile of cash to drug companies. That money didn’t just fall out of the sky. There is no such thing as a free lunch. The alternative is that the money gets spent elsewhere. It doesn’t disappear.

You’re not “handing a pile of cash to a drug company”. Those who can afford it are being charged more and those who can’t are charged less, so in the end the company makes a reasonable profit on average.

What’s the more efficient way to handle this? The money ultimately has to get to the company somehow – redistributing it via somebody else just adds another party to the transaction, with associated overhead.

Say that a company needs to charge $5 on average for a med to turn a profit. They have two patients, one can afford $10, but one can only afford $2. So they charge a retail price of $8 and give a coupon to the poorer patient so they only have to pay $2. You would prefer that somebody else (the government? A charity?) take $3 from the rich guy and give it to the poor patient so they can both pay $5 for the med. either way is identical, in that the drug company gets $10 and both patients get the medicine. But I fail to see how the latter example is more efficient.

This is invalidated if the company is making an exorbitant profit on average, but that’s just as likely in an “everyone pays the same” scheme.

The difference isn’t $2 vs. $8. The rich guy is paying 8% of $100 while the poor guy is being charged 20% of $100. The coupon means the poor guy is paying 2.4% of $82. The drug company is still getting the bulk of the money because the copay is only a small percentage of their fee. The answer isn’t for the government to pay for the drug. It’s for the patient to pay the price they’re supposed to be paying and make up their own mind whether the higher price is worth the value. In many, many cases there’s already an alternative on the market that’s much, much cheaper. The coupon is so the drug company can still extract most of their payment while still keeping their “prices” competitive with the much cheaper alternative. This reduces competition on price.

Well that was unkind. I read the Wikipedia article and I fail to see how it affects my argument. Drug coupons are discounts given for expensive drugs that are not covered by insurance or in cases where they have large copays.

In other words, they are a means to get drugs to those who otherwise couldn’t/wouldn’t pay the full price that “richer” (better insured) patients would pay.
To the extent that they have anything to do with affordability, which was the point of this sub thread, they are effectively price discrimination / “redistribution ” of costs. If a generic drug is available, well, there’s a reduced cost option already and the insurance company can always deny covering the brand name drug, coupon or no.

Can you explain in more detail why you don’t think my analogy applies?

Yeah, there’s the “kickback” angle potentially, but ultimately the drug company really is getting less money from you if they offer the coupon, so the price discrimination angle is apt.

My doctor prescribed Enbrel because she thinks it’s the most effective treatment for me. My insurance had a $45 copay. This was a bit unfortunate and it was stressful to think about the whole year, the possibility of insurance not covering at some point/losing insurance somday (not to mention the possibility that it wouldn’t even work out), but I ordered it because I was really sick.

When I actually ordered it they told me about the prescription assistance program and they canceled out my copay. That was awesome. The drug worked great, but I had a bad reaction so I got switched to Humira. That drug doesn’t have prescription assistance so I had to pay the $45. Then I reacted to that and I’m back to a different formulation of the first one.

So for me, this has had no impact on my actions, it has just helped me out sometimes, which I appreciate. I feel like once you get to these expensive drugs for serious illness a lot of people would have a similar experience. There may be situations where a doctor might say “these drugs are both good, but this one has prescription assistance so let’s use that because you are in a bad financial place” but I have a hard time seeing the problem with that if it gets someone treatment that they need that they would otherwise struggle to afford.

Price fixing is where competing companies agree to raise their prices and not undercut each other. Price discrimination is where a company tries to match the price it charges with how much an individual customer will pay. A kickback is where a person deciding how someone else’s money will be spent get a portion of that money returned to them. What you are criticizing is a mixture of price discrimination and kickbacks. There is no price fixing.

Goldacre’s ‘Bad Pharma’, while not perfect, does a very good job detailing some the more insidious practices.

As for people taking money from pharma companies whether as cash in duffel bags, expensive family vacations (a practice now banned I think), or large payments for being a speaker?

People who don’t think this affects their behavior (by that I mean either their beliefs going in AND / OR their ability to change their mind when new information comes in at future points in time) are deluding themselves to believe that they are unique and don’t belong to a reference class. Put differently, they’re in denial. Cialdini has done quite a bit of work on tools of influence, and for starters I’d say look at reciprocity and commitment / consistency. (As a footnote: it’s worth highlighting that long before Cialdini, Wal-mart banned everyone in procurement from taking any ‘gifts’, even coffee or donuts, from current or potential vendors– it’s worth noting as the most savvy [ruthless?] corporations are usually years ahead of academic research on human behavior.)

For people who say it all washes out via many pharma companies paying off many other practitioners, you still have a few problems. (A) is there’s no real factual basis to think that’s true at the individual adviser level — as with most business there probably are regional (or other idiosyncratic) differences in sales force effectiveness and so clientele are consistently getting skewed recommendations due to influence practitioners and these asymmetries matter– which reminds me of a variant of an old econ joke: one adviser tells his clients to stick their hands only in freezing water and the other tells her clients to stick their hands only in boiling water; a third economist walks by and remarks that, on average, the clients are comfortable.

(B), the practice of paying advisers off results in two forms of dead weight losses / inefficient resource allocations (1) you have an entire industry of people employed to curry favour with doctors while not disseminating unbiased facts, — these people could be doing something useful elsewhere, and (2) the large sg&a burden for ‘marketing’ specific drugs creates large scale economies that only a handful of large firms can match, which is a form of entry barrier.

Embedded in my comments is a belief that the marketing of the scientific virtues of healthcare products should be held to a different standard than say marketing the fun factor of a video game or the coolness of a new car or smart phone. Not everyone will agree that science and requires a higher standard.

I suspect that people think that the science has been done prior to FDA approval.

Note that at least outside of psychiatry there is an incredibly low compliance rate for non-drug practices to solve problems. People can take their lipator, but can’t restrict their intake of crap foods[1]. People will go in for bariatric surgery, but won’t restrict their intake of crap foods and get a little more exercise.

My mother was, for a very short time, employed as a Workman’s Comp nurse who would go to peoples homes to assist them in rehab. It really shocked her that *most* of the people she met with had *no* intention of doing anything to make their condition better because why should they when they got paid almost as well for not working.

Ask a (non-sports medicine) physical therapist about compliance. Hell, people won’t even finish all the *antibiotics* they’re given, leading to all sorts of bad problems, and all that is is taking pills for another 2-3 days after you start feeling better. The funny thing is the case that came to mind was of a junkie who repeatedly got Hep from sharing needles, and wouldn’t finish the course of drugs prescribed, until she got the drug-resistant version. Sucks to be her. And anyone sharing needles with her. And sleeping with her.

I’m guessing the problem is worse inside the psychiatric world–a FoaF decided he was feeling better and stopped taking his PTSD medicine. Yeah, that ended with a police standoff and a (I think) divorce because his wife didn’t like being held hostage. However, since people generally are under psychiatric treatment for mental problems and the mental bit is where compliance is regulated, they get a *bit* more of a pass.

So I have little patience with people who whine about how doctors are just shills for the pharmaceutical companies and their pushing pills and wanting to do surgery when people won’t do the most sensible, basic things for themselves–eat plenty of fresh fruits and vegetables and reasonable amounts of other fresh stuff. Avoid eating too much crap, and get a couple hours a week of *some* sort of hard exercise (and no, perambulating around the mall doesn’t count. If you’re not out of breath and sweating[1]) it’s not exercise.

But most people don’t want to do this. They smoke until they need oxygen, then go outside and take the mask off to puff some more. They drink their first liver into a stone, quit long enough to get a transplant, and go right back to it.

My own father, the one in the health care field–290 pounds (at 6’2″), smoked 2 packs of Salem 100s a day, and the only exercise he got was running off at the mouth and jumping to conclusion. From what I know now I’d say it was Congestive Heart Failure (he was really grey the last time I saw him, then again I’m not a doctor).

We increasingly live in a world where we expect Doctors to solve all our medical issues, and to do it cheaply and effectively while we sit on our couches and argue with people on the internet (no, I have a desk and a chair. Soon to be a standing desk and a perching chair).

[1] Except for swimming. You’re probably still sweating, you just don’t realize it.

I don’t see anything morally wrong with having doctors solve all my problems. If there existed a magic pill that would allow me to smoke all day and drink nothing but rum with no ill effects — I’d take it. Currently, such a pill does not exist (so doing all these things would be a monumentally stupid thing to do, as you said), but I don’t see any reason why such a pill shouldn’t exist.

Megan McArdle had a good post about compliance issues a while back. She quotes a back surgeon: “We know physical therapy is better [than back surgery] in most cases. What we don’t know is how to make the patients go to physical therapy.”

It’s the opposite of addictive. It’s long term, it tends to be painful, it tends to have little or no short term payoffs so every time you do your physiotherapy it makes you want to do it a little less because every single time is an unpleasant experience.

That sounds a bit harsh. I don’t think he was trying to claim that the standing desk is his exercise, merely that he is presenting his ‘not a couch potato’ credentials by showing that even his arguing-on-the-internet time is optimised for health so far as possible.

People can take their lipator, but can’t restrict their intake of crap foods. People will go in for bariatric surgery, but won’t restrict their intake of crap foods and get a little more exercise.

Sounds quite logical to me, assuming by “crap foods” you mean delicious stuff rich with calories, as opposed to nasty-tasting stuff. Constant denial is hard work for many people.

I got a taste of that after my second pregnancy: I didn’t gain any fat during the pregnancy itself but afterwards for about 8 months my appetite was incredible. If I was hungry I just couldn’t think about anything but food. My weight crept up, until my appetite switched back to normal, but that was far better than fighting the hunger.

Constant denial is basically impossible. Nobody can tolerate being hungry all the time. However, there are certain biological hacks that can be used – low-carb high-fat diets, for example, are very popular for this reason. There are a variety of posited explanations for why this is so; probably the least controversial is that fat and protein are much more satiating than sugar, so people voluntarily restrict their caloric intake.

It’s not so much the sugar with low-carb diets (you can always find a substitute sweetener or grit your teeth and give it up altogether), it’s things like bread and rice and potatoes because there aren’t substitutes for them the same way.

Oh dear God, so hard for me to cut back on potatoes (yes, I’m Irish). Also, eating your five healthy portion of vegetables a day is tough because a lot of vegetables are starchy or high in carbs: parsnips for one, but carrots are also a bit iffy.

Luckily, I like celery so I can eat it till it comes out my ears, but it is rather limiting when your choices are: lettuce, celery, cauliflower, broccoli – particularly when no béchamel sauces to pour over the horrible green stuff because flour!

Deiseach: Don’t forget spinach! That’s the best vegetable out there!
If you want good dressing, use olive or coconut oil. You can add spices to taste. Better than store-purchased dressing for both the palate and the body.

Saying “I don’t think being given free pizza affects me” is a lot like saying “I don’t think advertising affects me”. Yes, it does, even though your conscious mind probably doesn’t think “I will buy that because I saw it in an advertisement”.

Yeah, but I think it’s different when all the companies are giving you free pizza. If it was only one company, then just as giving speeches as the medical representative of Wundadrug Inc would be corrupting, so too would taking the goodies from one company.

But if you prescribe the latest free sample you got, and all the samples are of drugs that are much of a muchness so it really is a coin-toss and with a particular patient, you might be switching between drugs to see which works anyway (I see this with my sister and her anti-depressant prescriptions; every so often her doctor overhauls these and when one stops working so well, she’s put on another one) – then sure, why not take the pizza from Wundadrug Inc – so long as you’re also taking the sandwiches and coffee from Amazo Ltd and the hotdogs from Marvell plc.

Equal opportunity corruption, in other words; no preferential bribery 🙂

Interest in social justice issues is correlated with being personally affected by relevant issues. People with menal illnesses are affected by ableism obvs but there’s also the kind of cyclical thing where crazy people are more likely to be sexually assaulted and victims of the same are likely to develop certain mental health issues.

It’s also more acceptable in SJ and adjacent circles than nearly everywhere else to be open about being crazy which will inflate the apparent proportion of crazy.

It was because in order to get the FDA to approve anything for anything, you must perform the appropriate ritual of putting a zillion dollars into a big pile, then burning it as a sacrifice to the Bureaucracy Gods.

For values of “burning it as a sacrifice” that include literally amassing semi-truck trailer loads of documentation, spending thousands of FTEs on development studies and such and it’s *still* a crap shoot when the Feds start looking in.

My father was in the health care field–mostly a instrument and pacemaker salesman–from the late 50s into the late 80s/early 90s. He watched the medical care field change *enormously* during that time. When he started in the field he would show up in town (traveling salesman), make a few calls, line up a few lunches and dinners with doctors over the next 2-3 days (literally making appointments for the next day), and when he walked into an office the doctor almost always made time to see him.

By the 90s you had to make appointments 2-3 weeks out because the doctors were so busy.

And I think it’s also this last thing–right now doctors, especially those who are doing general practice, ER and (sorry, don’t know the technical term) “front line work” (the first doctors you go to before being handed off to specialists) are incredibly busy. They don’t have 36 hours a day to see patients, do the paperwork, keep up in their specialty and research all the chemical compounds out there, so they have to find a balance somewhere.

I think that the sales and marketing arms of most companies (not restricted to the Pharma industry) are…ethically challenged, and one of the tomes that has fallen back from the future can be read to indicate that in the revolution it was the marketing folks who were first up against the way…well, right after the mime. Nobody liked them. No, that invisible wall will not stop the bullets.

Anyway, we’re surround by people who utterly lack integrity and honest, which brings us to John Oliver, John Stewart, and Stephen Colbert should be legally required[1] to wear red noses, big floppy shoes and water spraying boutonnieres. They’re f*king clowns, not even Jesters. They pretend to be journalists, but when called on their bombast retreat behind “It’s a comedy show”.

[1] No, not really. There’s very few new laws I’m in favor of, and most of them involve letting the police beat people for driving on bald tires in the snow, not clearly off their windows sufficiently and failure to maintain at least 2 seconds following distance.

Is the reason doctors are so busy today just because of greater demand? What exactly is forcing doctors to be so busy?

Is it possible to get a medical degree, open up a practice, and refuse to work more than 40 hours a week for any reason (and I mean 40 hours of work total, not 40 hours of seeing patients and more hours of doing paperwork)? I imagine you’ll make less money than a doctor who works normal hours, but if that doesn’t bother you is it possible? Or is there some way the medical profession has of making that not an option? Obviously there’s probably some legal liability that requires you to fill out paperwork on time, but it seems like you could adjust for it by seeing less patients.

Sure, you can, but most people don’t open up their own practice. Even if you have a small practice with 6 doctors, there’s a lot of pressure to work the same as the others. (I don’t think William was talking so much about overtime, but about being very busy during the day, but the same applies.)

It’s possible, of course, but at that point you’ve wasted a substantial portion of your life acquiring a very, very expensive education (in both time and money, with typical debt loads approaching $200k at a public med school), and from a financial perspective anyone bright enough to get into medical school could do much better in the long run just getting a normal job – it’s not like the alternative to med school is working at McDonald’s as a fry cook.

Long story short, if you are in private practice, you have to pay for overhead, which includes rent, equipment, staff, and the electronic records system (<–this is VERY expensive, is outdated every 5 years, and needs to be completely replaced.). so you have to work a lot more than 40 hours to keep your practice afloat or else you close up shop. Plus, many docs will have to be on call at the local hospital in order to get the privilege to admit your patient in case something goes wrong. So the hours can balloon anywhere from 60-90 hours per week depending on specialty (could be 120 hours if you are a neurosurgeon). Sure you can just work 40 hours a week strictly, but that is considered part time and your pay check will be slashed by up to 50%, depending on your contract. This is not possible if you own your own practice because you will go under.

If you work in a hospital, then you will have to be on call a lot more (typically). I know surgeons who had to wake up at 1am because they were on call, perform surgery for 4 hours and not get paid for those 4 hours. After their 4 hour surgery, they immediately have to start their normal 6am-6pm day. If you want to work strictly 40 hours, they might fire you or again cut your salary significantly. They can hire someone else who will work those 60-80 hour work week without complaining.

The exception is Emergency Medicine. You work around 32-36 hours a week (more if you want). But you have to do day and night shifts. This causes a lot of problems because you mess with your circadian rhythms and the ER is so busy that you often burn out, which causes problems with your lover back home. And you have to work on major holidays (think Christmas, New Years, July 4th, Thanksgiving, ect).

It’s a bit of a tradeoff for the insurance companies, but in general not really.

Insurance companies have to cover a lot of new drugs because they *do* work for many people in many situations.

If a drug has made it through the FDA hurdles with only a normal amount of fudging and fraud it’s *pretty* safe when used as directed, and it’s going to pretty much do what it says on the label for a significant fraction of the population. This is why we *have* insurance[1] to covering large, unexpected medical costs, and if insurance companies stopped covering specific drugs the amount of prescriptions for that drug would drop–as Dr. A notes there are at least 2-3 drugs that cover a specific issue, and *most* issues can be managed with older drugs (maybe not in Psychiatry), and if when you go to a doctor and say “my insurance won’t cover this” they go to another molecule.

So basically insurance companies, for regulatory and commercial reasons have to cover most drugs that have passed FDA approval and are being used within reasonable scope.

However being covered by the Insurance Company generally means that the insurer has negotiated a reduced price, so there’s less money there to be made (you want to upset the Health Care Payment market? Simply legislate that any hospital, clinic, or medical provider receiving government monies *in any way* cannot charge the uninsured/cash price more than 5 percent of the *lowest* price negotiated with the insurance industry. PURE CHAOS ERUPTS! Hail Eris!)

In fact here are the top 10 prescribed drugs (2010) and the year they were invented/discovered (as best I can find):

Hydrocodone (combined with acetaminophen) 1959
Generic Zocor (simvastatin) 1979/early 80s.
Lisinopril early 1980s
Generic Synthroid Since at least 1938. See here http://tiny.cc/g3j8tx for some more evidence of poor ethics and integrity fail in the industry.
Generic Norvasc first patent filed 1986
Generic Prilosec Patent filed 1984
Azithromycin Patented in 1981
Amoxicillin First available 1972
Generic Glucophage (metformin) first described in 1922, 1958 available in Britain, 1970s in Canada, 1994 in the US.
Hydrochlorothiazide around 1958.

So of the top 10 drugs prescribed (as of 4 years ago 🙂 ) all of them are old enough to have generic counterparts (which is, itself, a completely different issue).

As new drugs come up, they not only have to compete on effectiveness and short term side effects, but also with a doctors comfort level. The effects of, say, Ibuprofen are REALLY well known because we’ve had lots of all kinds of people taking it for both long and short terms. Naproxen (Alieve), not so much (but it’s probably a little better?).

[1] Or did until it increased to 14% of my take home pay AND wouldn’t cover anything at all for the first 3k person/6k family.

The Daily Show and all of its alumni basically have no idea how medicine in general works, and think that money has magical virtue-annihilating properties such that in any dispute, the person with more money is always wrong and the only thing that needs to be pointed out is that they have more money.

TDS itself did a segment last year where they gave a platform to a crazed conspiracy theorist about how Big Pharma had the FDA in its pocket and all the companies were conspiring to give out harmful untested drugs (it was a specific kind that I can’t recall off the top of my head, but I know that a full half of the companies he named as in on the conspiracy never ever made anything like that drug). They had Jason Jones (I think) go out and interview a drug company rep as part of their bit. The rep explained very calmly how absolutely baseless these accusations were. Jason Jones just went “Wait, they’re paying you, aren’t they?” and left the interview. Then he continued on with the bit about how the evil drug companies were conspiring to kill us. There was no subversion, there was no message of doubt — his logic was, literally and explicitly, this person is being paid money so this person CANNOT SPEAK TRUE WORDS.

Every time someone tries to tell me that the drug companies own the FDA, I point out “If you make a new medicine, which takes thousands to millions of man-hours of very very highly trained experts, you get exclusive rights to it for 7 years from the moment you STARTED your research. If you make a new fictional character on a napkin, you get exclusive rights to it until the Sun is cold and dead.”

Wait, what? You only tasted the forbidden fruit once? I thought you attended medical school on the same island as me, where the free pharma lunches at the hospitals were the highlight of the day for any med student?

Particularly this was the case at Our Lady Of An Undisclosed Hospital two hours north of the capital. When you’re stuck in a dump like that for weeks, there is no amount of ethics that would stop me from “taking their soup”

I never felt bad about this because I could never remember which drug company provided the food anyways. This was the only time in my brief medical career where my inability to remember things came in useful.

You’re right, I did have pharma lunches as a med student a couple of times at journal clubs. And now that you mention it, I had them a couple of times at clinics where I was working.

Those didn’t stand out because they didn’t seem like me accepting anything – I happened to be in the room where a pharma lunch was the only lunch on offer. The dinner I went to was the only time I personally consented to something where I knew pharma was trying to influence me.

Neat to see another Irish med student here, although given your description of your location I doubt we crossed paths.

Deiseach, you are right, I overestimated the travel distances in your country (this is almost a decade ago – hopefully that excuse works better for me than it did for Brian Williams). I guess I will have to unmask the undisclosed location to preserve my credibility

Something that has been bothering me for a while is why all kinds of healthcare seems to be insanely expensive in the US compared to everywhere else. The second on that list is Norway with a cost 2/3rds of the US. Norway is a stupidly affluent country (like we’ll put a 14% tax on giving someone a job – not because we need the money for anything, but to curb the rampant wage increases affluent) so it should be the other way around.
Looking at prescription medicine specifically, it seems to be even worse.
And this seems to have a direct effect on completed treatments.

Why is this? Naively, I would expect a market with several competitors to drive prices down, not up, but that seems to be contrary to evidence?

The last article you linked does suggest a few explanations. In short, some of the reasons are neutral (the US is a lucrative market in terms of needs and wealth), and some are bad (advertising to patients + decisions made by doctors + prices set by companies + payments made by insurers = total mess, worse than either free-ish market or single-payer systems).

They’ve got some decent content overall, though I gotta say their most recent video disappointed me badly. It has a really terrible use of statistics in it, in which it compares lifespan-at-25 by educational attainment over time among white women, and concludes that life expectancy has dropped sharply for highschool dropouts. Problem is, it does this while completely ignoring the massive change in the proportion and therefore composition of the demographic that drops out of highschool. And it actually may be even more directly confounded than that, because (though I haven’t been able to find a direct answer to the question yet) all the data I’m seeing on why people drop out suggests that major health issues (personally or in the immediate family) is second only to pregnancy as a reason that female students fail to complete highschool. At which point the comparison being made isn’t just irrelevant, the causation is reversed. Ugh.

I think the fundamental thing people don’t fully understand about healthcare is that it is pretty much a unique market, in the sense that it behaves almost nothing like any other market in any other field. Even the Supreme Court apparently don’t grok this, because in the Obamacare rulings they had a lively discussion about whether Justice Scalia could force people to buy broccoli if Justice Roberts could force them to buy health insurance, belying an implicit belief that broccoli and health insurance were the same kind of product from the purchaser’s point of view. That’s not to say that healthcare is somehow magically immune to ordinary economic incentives, just that the structure of the market for health is absolutely bonkers compared to the market for broccoli. Consider the following facts about a typical healthcare market:

* It follows a principle-agent model, so I have to trust that the doctor is providing only the care I need and not the care that is most lucrative for them (considerable evidence exists to show this is a problem even in the UK, and it is as beyond doubt as a question in the social sciences can be that it happens in the US)

* There is impossible asymmetry in the market; insurance providers cannot observe how healthy you are when you apply for insurance and patients are canny enough to lie if asked, so the result is that the healthy are under-insured, the ill (and elderly) are over-insured and the poor are shafted.

* Demand is irregular, and I can’t predict my need for healthcare in advance, meaning I can’t take steps to reduce my other consumption before I consume healthcare. There’s also no meaningful substitute to healthcare, meaning it is difficult to avoid the failed market.

* Production is irregular; I pay for *healthcare* but I want *health*, and I can’t guarentee that my purchase of healthcare will result in health. On the other hand the production inputs of healthcare (doctors, mostly) are restricted by licensing, artificially creating an – important – barrier to entry

* There are a meaningful number of times when we cannot assume a rational consumer. Obviously mental health issues as a massive problem for philosophically-inclined economists, but also times when people are delirious from pain, unconscious or urgent admissions and are unable to make a rational choice between two competing providers.

* Your usage of the medical system affects my future usage (immunisation is the obvious one, but treatment for mental health is one of the most all-encompassing failures of most modern healthcare systems). I have a direct interest in your being insured that goes beyond a mere preference for your not falling ill.

There’s a couple of other more technical reasons healthcare is a ‘failed’ market by conventional standards (particualrly one about insurance risk pooling by Rothschild and Stiglitz if people want to google it), but that should hopefully give you a flavour of why competition doesn’t drive down prices in America – competition only drives down prices if *every* assumption of efficient markets is true(ish), so when you find a market where almost none of these assumptions are true it is unsurprising when it behaves in a less-than classical way with respect to competition.

The next question is – given that – how come the US spends so much more than everybody else? It’s a super-complicated question, but my guess is that there are a few specific factors which exacerbate the general market failure trends I outline above. Someone links The Incidental Economist article above, which concludes you can explain about 33% of the deviation from a simple wealth vs healthcare spending fit with things like paying extra for drugs and doing more procedures. I think some other factors which might explain the remaining 66% are a lack of effective healthcare rationing (like NICE in the UK), a lack of effective risk control mechanisms (which is exacerbated by a perculiarly American focus on diagnostic equipment, meaning people recieve expensive treatments for diseases which aren’t going to kill them) and a particularly pernicious implementation of the principle-agent problem (AFAIK, most Americans don’t buy healthcare, their employer does. And most insurers don’t provide healthcare, a hospital does. So nobody actually using / providing healthcare has any incentive at all to care about how much they’re spending. In a nationalised model, at least the provider of insurance is also the purchaser of healthcare, so they stand a chance at bilateral negotiation).

I also have a feeling economic inequality might contribute – if people aren’t being diagnosed early with things like diabetes because they can’t afford to visit the doctor because they are uninsured then the first the system will know about them is when they present at A&E needing a foot amputation (this is a huge problem with some minority communities in the UK, where the culture is not to go to hospital until you’re at death’s door). Some people argue that ‘medicalisation’ is also to blame (people turning up to hospital with a disease they would have previously self-managed) but that sounds like a pretty complicated problem-within-a-problem and isn’t something I know a lot about.

Also, please could somebody tell me how to embed links? I have a couple people might find interesting but I didn’t want to risk mucking around with the HTML tags.

Well, the way you embed links is you use the html tags. It’s [a href=”LINKGOESHERE”]text that displays goes here[/a] but with angled brackets instead of square ones.

You could also just paste the addresses directly into the body of your post.

RE: Medicalization, this estimates it at <5% of US costs. Which isn’t nothing, but the “we’re wimps who want doctors to solve all our problems” theory probably isn’t one of the major factors even if you expand the definition beyond strictly the creation of new categories of medically-treatable problems.

BTW, there are several ways to have an HTML tag displayed rather than evaluated. One is to type &lt; for the “less than” symbol and &gt; for the “greater than” symbol. So, for instance, if you type &lt;br&gt;, then <br> will be displayed.

Are you based here in the UK Froolow. If so, I want to see what the solutions are for optimising the NHS. Just write the links.
I work in this industry so no names of course – but I will point out that I am requested by medics to provide lunch at least as often as I might suggest it – in fact to get to see some people I basically have to. Most people actually give me a real grilling – which keeps me on my toes I suppose!

Edit: Sorry all, these long replies are absolutely brutal to the nesting. I’ll try and keep everything briefer from now on.

Yes, I work in the UK. I’ve worked both for the pharma and government sector and your experience echoes mine – most doctors are sufficiently sceptical of pharma reps to give them an absolutely brutal grilling, but I’m certain the advertising must be doing *something*, because otherwise the companies wouldn’t pay for the reps (when I was working pharma side every couple of months someone would come up with a bright idea on how to sell drugs without a sales force, and none of them ever, ever worked. It’s one of those ‘zombie’ ideas which everyone reinvents all the time). About ten years ago the situation was completely out of hand – pharma reps would bring a laptop to demonstrate a powerpoint and then say to the doctor, “I don’t need this anymore, you keep it”, but now the relationship seems much more healthy. Doesn’t mean I totally approve of pharma industry ethics, but I think they’re going in the right direction.

In terms of improving the NHS, I think there are a couple of things which need to happen urgently (as in, next five to ten years) to give us all a bit of breathing room to work out what to do with the aging population and ailing infrastructure.

The first of these is to take a politically suicidal decision to lower the NICE cost-effectiveness threshold from (effectively) £30,000 / QALY to around £18,000 / QALY. For those of you not following this technical discussion, the ‘cost-effectiveness threshold’ is the amount the NHS is willing to pay for the equivalent of one additional life year (this is – by definition – the opportunity cost of healthcare at the margin). When NICE was set up it used £20,000 – £30,000 as a kind of ‘placeholder’, but £30,000 has become the de facto standard by which new technologies are judged. This article suggests that £18,000 is roughly correct (and the technical paper it is based on is really very good too) and that by failing to institute an £18,000 threshold we’re failing current and future patients by displacing healthcare we know works (physiotherapy, say) in favour of expensive healthcare at the margins of cost-effectiveness (knee replacement for very overweight people, say). The reason this is political suicide, however, is that it would mean essentially leaving a lot of cancer patients to die in favour of saving ‘statistical’ lives. You also then need to credibly hold to this threshold, rather than e.g. creating ‘cancer drug funds’ to carve out exceptions for politically important subgroups

A similar level of political thanatos would be needed to close a lot of specialist units and A&Es and set up regional ‘super units’. I don’t work in this area so I understand it a little less well, but the basic argument is very easy to follow; a specialist unit needs (say) specialist diagnostic equipment which is only cost-effective if it treats 1000 patients a year. If ten specialist units are treating 100 patients a year each then each unit is haemorrhaging money (and also probably providing suboptimal care, because the clinical teams don’t get enough practice on the really hard cases to keep their edge). This is also political suicide, however, since any MP that agreed to the closure of their local A&E in favour of giving more money and political influence to another constituancy would very soon be out on their backside, and constituants are very vocal about letting MPs know this.

Finally, I think the NHS needs to start getting a lot ‘rougher’ with people we know are going to develop diseases. For example in one area where I work there are a lot of patients on a list of people with abnormal heart rhythms indicating atrial fibrillation, but then not showing up on the list of people who are being prescribed a drug to control their atrial fibrillation. Everyone acts as though this is a difficult problem, but to an economist it really isn’t; on average about five in every hundred of those untreated patients are going to have a stroke they wouldn’t have had on treatment and maybe another five will have a preventable heart attack. Given the rough costs of these adverse events, the NHS would be in the black if it paid someone £100,000 a year to go to one hundred of these people’s houses and shout at them until they agreed to see their GP for a discussion about warfarin (OK it maybe isn’t quite that simple because some people will contra-indicate. But it certainly isn’t as hard as many people believe; it just requires that people understand money is fungible across different parts of the NHS). This isn’t political suicide like the other two issues, but it is quite difficult to get comissioners interested in – the kinds of solutions that work for these problems are not high-status.

I also think – and this is just a personal view – the government could tweak the incentive structure of pharma a little bit. If they precomitted *now* to paying £5bn to the first company which could demonstrate a nonintrusive regime that reverses Type 2 diabetes / dementia provided the company precommits to selling that drug at cost in the UK then companies would have a strong incentive to gear up their R&D to invest in low-probability high-payoff drugs, rather than the trend at the moment which is to invest in high-probability low-payoff ‘nichebusters’ for neglected disease areas (and then use mechanisms like the cancer drugs fund to carve out exceptions to the £30,000 / QALY limit and turn those drugs into high-probability high-payoff outcomes!)

No, please don’t. The page formatting here is kinda terrible, but I’d much rather read long informative posts that are scrunched into a thin column than shorter, less informative ones.

A similar level of political thanatos would be needed to close a lot of specialist units and A&Es and set up regional ‘super units’.

Interesting that the NHS has this problem. The U.S.’s miniscule population density is a major factor adding to its total hospital infrastructure costs, so I assumed most of the European systems were working to capitalize on their geographical advantage there.

Thanks for the reply Froolow and apologies for the delay in coming back.
Ok, the 1st two links didn’t work – but I’m not quite following – are you saying the threshold for approval of a new drug/procedure, etc. should be lower so that where now cancer drug costing £3k per dose is not put on the pathway but in the new system it would be?
I have more questions to follow! Sorry, but there’s so little healthcare economics out there, does no-one do phds in it or something? Everyone does macro which is… well macro is macro I guess.

We’ve hit the limits of the nesting here, but if you have more questions to follow my name on reddit is the same as my name here and I’m more than happy to carry on answering questions (that goes for anyone with an interest in the topic – please feel free to PM me)

Just incidentally, by the power of the Baader-Meinhof Phenomenon, this exact issue is in the news today:

It looks like you followed the instructions you were given, but unfortunately the quotes in the instructions got converted to smart quotes. With any luck you’ll be able to cut and paste this: <a href="url">title</a>

Thanks for a great comment. So frustrating that what needs to be done is political suicide 🙁

I also have a feeling economic inequality might contribute – if people aren’t being diagnosed early with things like diabetes because they can’t afford to visit the doctor because they are uninsured then the first the system will know about them is when they present at A&E needing a foot amputation

On the purely financial side, if someone doesn’t visit the doctor until they show up at A&E needing a foot amputation, then they’ve saved a lot of money compared to someone who shows up at the doctor having a freak-out over every minor ache and twinge (says she who has had her freakouts). They also save money compared to someone who was diagnosed and treated for diabetics but didn’t follow the lifestyle bits and needs a foot amputation anyway. I have a relative in mind for the latter.

> There is impossible asymmetry in the market; insurance providers cannot observe how healthy you are when you apply for insurance and patients are canny enough to lie if asked, so the result is that the healthy are under-insured, the ill (and elderly) are over-insured and the poor are shafted.

This is utter nonsense. I sell personal insurance, including health insurance(though Canadian health insurance, which is for things like drugs and dental). The questionnaires and tests my clients go through are sufficiently invasive that it’s hard to hide much of anything, and if they do manage, the response is a polite “You intentionally lied to us? Your policy is null and void, here’s your premiums back”. This is a solved problem, and the only reason for it to be an issue is ridiculously bad laws.

> Demand is irregular, and I can’t predict my need for healthcare in advance, meaning I can’t take steps to reduce my other consumption before I consume healthcare. There’s also no meaningful substitute to healthcare, meaning it is difficult to avoid the failed market.

That’s not how market failure works. And if need is irregular, that creates a reason to save and insure, but it doesn’t make it unique by any means – car repair needs are irregular too, but nobody suggests we get a federally mandated oil-change insurance plan.

> Your usage of the medical system affects my future usage (immunisation is the obvious one, but treatment for mental health is one of the most all-encompassing failures of most modern healthcare systems). I have a direct interest in your being insured that goes beyond a mere preference for your not falling ill.

So you favour forced treatment of the mentally ill? And even if you do, why does that result in an insurance mandate of all things? Insurance is a financial product, not a medical product.

Don’t just take my word that the theory is correct though – if the market for insurance is not functioning well in America we would expect to see a lot of Americans who have not purchased healthcare insurance because the market can’t profitably separate high-risk from low-risk patients in that sub-group. In actual fact something like 50 million Americans are unwilling or unable to purchase health insurance at any price the market is willing to offer it to them, which appears to describe a badly functioning market almost perfectly; if both sides could perfectly estimate their risk then this uninsured group should not exist.

> So you favour forced treatment of the mentally ill?

I don’t think that comment is fair. I even pre-emptively defended myself from that kind of accusation by pointing out that what to do with mentally ill patients is a seriously difficult ethical issue for philosophically-minded economists. But I don’t think anyone can deny that mentally ill people crop up a lot in healthcare, and also present a very serious challenge to the idea of a perfectly efficient market. But I guess you’re right that I have an interest in your being ‘healthy’ rather than ‘insured’, so I mis-spoke.

Why are uninsured Americans automatically a market failure? We don’t call the auto market a failure just because some people walk. Also, the 50 million uninsured Americans number is mostly bogus – about a third of them aren’t actually Americans(they’re immigrants, legal or illegal), a third aren’t really uninsured(they’re either uninsured for short periods between jobs, or they’re Medicare/Medicaid eligible and just haven’t signed up), and a sixth are either very young or relatively wealthy and are basically just self-insuring. The sort of uninsured person people like to talk about is only a few percent of the country. Which isn’t to say it isn’t real or worth trying to fix, of course, but I value good stats over bad ones.

I thought the idea of the broccoli and the health care comparison was that both were considered Good For You, so the idea was ‘can people be compelled by law not alone negatively – e.g. don’t do that or you’ll be fined/put in jail – but positively, e.g. eat healthy food/buy health insurance or you’ll be fined/put in jail’?

RE: the foot amputation of diabetes – I’m two years diagnosed with Type 2 diabetes and the lovely reassuring message I got was “You ARE going to develop retinopathy/kidney failure/circulation problems in your legs/possible amputation. The goal we’re aiming for is to stave these off as long as possible by good blood sugar control, etc.” Because you’re going to be living with diabetes for the rest of however long you’ve got, it’s progressive, it does cause damage and in the end, this is the kind of damage it causes.

So it may not be that people aren’t going in to be diagnosed, it may be that they’re diagnosed and after five years of worrying ‘is this the year my eyes/kidneys fail?’, they get depressed, backslide on things, and then turn up with the inevitable (as I’ve been assured these things are inevitable) end problems?

Just curious: What fraction of bills in the US for serious surgery (defined for the purpose of this question as those requiring an overnight stay or more) are for more than the net worth of the patient?

I am interested in separate answers for patients-in-general and for non-indigent patients.

“but that should hopefully give you a flavour of why competition doesn’t drive down prices in America – competition only drives down prices if *every* assumption of efficient markets is true(ish)”

You seem to think the market in healthcare in America is even given a chance. But over 50% of the healthcare spending comes from the government already (and this is increasing). The government (state and federal) also has piles of regulations: certificate of need laws, occupational licensing and quotas restricting supply, plus many bureaucratic and expensive rules for Medicaid/Medicare participants. Not to mention the incentives to employer-tied insurance and the mandates on insurance. That’s not to mention the role of the FDA, subsidies (uncompensated care scheme which jacks prices up), different standards of care compared to other countries, and incentives from the justice system.
So while it’s true that each industry has unique characteristics, most of the spending in healthcare is on chronic or predictable treatment (which means there is relatively time to shop around, assuming competitors are legally allowed to enter the market). Ultimately, huge profit opportunities tend to attract those “greedy” entrepreneurs to provide better service.

Interestingly, the doctors and institutions that deal directly with customers (instead of through insurance or government programs) tend to post their prices and have more reasonable prices, compared to incumbents (who have notorious crazy pricing schemes).

Even the Supreme Court apparently don’t grok this, because in the Obamacare rulings they had a lively discussion about whether Justice Scalia could force people to buy broccoli if Justice Roberts could force them to buy health insurance, belying an implicit belief that broccoli and health insurance were the same kind of product from the purchaser’s point of view.

I’m very grateful for your thorough explanation of the interesting and unique factors that are involved in the healthcare market, but you’re missing the point of the Justices’ inquiry. They were not asking, “Is the healthcare market unique from the purchaser’s point of view?” They were asking, “How does this regulation relate to the Commerce Clause?” While the petitioners tried really hard to claim, “The market is unique, and thus we can’t compare it to anything else,” this reasoning is off-point. Which of the reasons that you gave (or combinations of reasons that you gave) makes the healthcare market unique for the purpose of Commerce Clause analysis? Distinctions which are not specifically relevant to Commerce Clause jurisprudence can still be distinctions for other purposes… they’re just not relevant to the Court.

Really, you completely omit the fact that the government is heavily involved in the US healthcare sector? You also neglect to mention that Americans eat a much worse diet than Europeans and are much less active? I guess you just omitted all evidence that government is the problem in healthcare, and not the solution for reasons of personal bias. And we wonder why economics is such a dysfunctional field?

Apologies, I went abroad about a week ago and didn’t see your comment.

The reason I omit the government sector from my analysis is that the US government spends almost exactly the same on healthcare (as a % of GDP) as any other developed Western nation. It spends slightly more than the UK (about 8.3% compared to 7.8%) but slightly less than France (9.0%), Germany (8.6%) and Denmark (9.6%), all four of which could fairly lay claim to having ‘the best healthcare system in the world’. If government intervention was the sole cause of a dysfunctional healthcare system then France, Germany and Denmark would be just as dysfunctional as the US. Source. Alternatively we could look at per cap spending to try and control for the fact that some countries are richer than others (since healthcare is a normal good) and we find that the US has an unexplained gap of about $2000 / person which is not explained by their relative wealth per capita. Source In fact my impression (speaking just from memory and without data for a moment) is that the government-run bits of the US healthcare system (Medicare and Medicaid) are respectably run as far as these things go, and the US dysfunction lies in the market system which sits on top of that.

Your comments about obesity are interesting. Perhaps as much as $25bn of the $650bn US spending ‘excess’ can be accounted for by US obesity, so not exactly small change but hardly the be all and end all. You also need to contextualise that by pointing out the US smokes a lot less and is generally younger than most of Western Europe (not to mention it doesn’t have anything like the mental health issues which afflict the Scandanavian countries). The UK is approximately as obese as the US (c.60% to c.65%) and doesn’t have the same level of catastrophic overspend as the US, which limits obesity as an explaination in my mind. Source

It doesn’t really seem fair to snipe at healthcare economists for being a “dysfunctional field” when you could do a first-order check for your claims in five minutes and see that either the arguments are much more subtle than you are claiming or that people who study this really *do* know what they’re talking about when they don’t list obesity as an important cause of US overspending.

It’s largely ineffective because of measurement problems. Definitionally, the sickest anyone ever is is in the time leading up to their death, and we tend to spend money on sick people in proportion to how sick they are.

After the fact, it’s easy to say which treatments don’t work, but in the moment it’s less easy. There’s gains that can be made here – people are too eager to yell “DO EVERYTHING FOR MY MOTHER!” and not eager enough to say “Maybe three days of lying in agony incommunicado isn’t really the way she wanted to go out…”, but fewer than is commonly believed.

My mother used to work on the board of a charity for helping people with brain injuries (one of my brothers survived a severe one). This board and the other committees/working groups/etc obviously included some people with brain injuries. So at first she spent a lot of time pondering if someone being very difficult was that way because of a brain injury or not.
After a while she determined that all the most difficult people were the non-brain-injured ones.

Fire in a nut-house. Doctors and nurses were freaking out. Y’know, we’re all gonna die, all that. And then the paranoids quietly led everybody to safety. Y’see, they knew something bad was going to happen. So they’d already checked out the exits. They were prepared.

So, after I picked myself up from the floor and wiped away the tears from laughing…

(1) Of course the names of the drugs are supposed to provoke exactly those kind of unconscious mental associations! That’s exactly what we sneaky verbal-oriented types do, and be warned dear maths geeks who use words like “satisifice” and think it’s perfectly cromulent, those humanities graduates whom you looked down your noses at in uni because you were doing REAL PROPER TRUE HARD SCIENCE and they were doing flower-arranging are now EXERTING MIND-CONTROL ON YOU THROUGH THE POWER OF WORDS 🙂

(2) A feckin’ bottle of Coke (even though I like Coke) and two biccies isn’t going to bribe me. If they’re going to provide a week’s worth of lunches, it better be one (1) free coffee and some decent sandwiches 🙂

(3) I don’t know why you expected anything different from the get-together; if you didn’t think the nurses would be bitching about doctors, the clerical officers would be bitching about the doctors, the doctors bitching about how the nurses think they’re doctors, and everyone would be bitching about the social workers, then (a) you haven’t been reading what I’ve been saying about social workers and (b) you know better now.

Speaking as a patient (and given that I have a doctor’s appointment on Friday), I wouldn’t object to my doctor getting a boxful of free samples and throwing one at me to go “Here, sure try this and see if it’s any good!” It can’t do any worse than the general range of normal stuff that’s prescribed, if it does make me worse then I’m a martyr to science, and if it works, then I’ll feel better (for as long as the free samples last, anyway).

Anyhow, one of my brothers works for one of those Evil Pharmaceutical Companies (try rearranging the letters “K”, “G” and “S” and see if you can figure it out) making the pills you get pressed into your hand by beautiful drugs reps, so for the sake of his continued gainful employment, keep taking the tablets! 🙂

Contrarian hypothesis: The placebo effect being real, a product with a name that sounds more effective will be more effective. Therefore, all else being equal, doctors should prescribe the medicine with the more effective-sounding name.

I wouldn’t be surprised if a nice name boosts the placebo effect – just because a compound has real above-placebo pharmacological activity, doesn’t mean the placebo effect isn’t important.

In fact wasn’t there a study on painkillers (or something) that found that real painkillers beat placebos, branded placebos beat generic placebos, and branded real painkillers beat the same pills in generic packaging. Also that two placebo pills are better than one?

‘Scuse me, sir, I have higher standards of bribery than that. I’m not so cheap as to be bought off with a 500 ml bottle of soft drink and two biscuits out of the packet for everyone, I want an individually packaged sandwich that’s not the ordinary run of the mill cheese and pickle and a brand name coffee 🙂

It can’t do any worse than the general range of normal stuff that’s prescribed, if it does make me worse then I’m a martyr to science, and if it works, then I’ll feel better (for as long as the free samples last, anyway).

If 100 days of a free sample showed me it worked, then I couldn’t afford it after that, I’d emotionally freak out (probably daily for each of the whole 100 days). But I’d definitely choose to try it. It would give a big clue as to what kind of ingredients helped me, I could search for cheaper stuff like it (me searching smarter during the 100 days), my doctor would know what cheaper stuff to look for, I could watch for the price to come down, and the horse might learn to sing.

I’d be more likely to believe the claims about verbal priming if they were based on larger samples with better controls and done by people who knew statistics. On those rare occasions when the research was done right, the effect size turns out to be minute.

The tone of this comment really, really irritates me. It basically serves to elevate the posters status, for reasons that don’t even make sense. Despite being fairly long, no useful information is contributed.

1. “I am great because it’s obvious to me (unlike you stupid math majors) that drug names are meant to convey positive associations!” I don’t think anyone was implying that describing this marketing tactic is some sort of earth-shattering revelation.

2. “I am great because I would not be swayed by drug manufacturers (unlike you stupid doctors)!” Literally the whole point of the OP was that you probably would be swayed and shouldn’t imagine yourself as especially virtuous.

3. “I am great because it would have been obvious to me in the specific scenario you describe what would happen at this specific party! (Also, have you not been reading everything I write?)” Uh, okay, cool.

I realize that I’m being just as bad by writing a comment with no point but to tell another commenter I think she’s obnoxious, but I feel like I see this poster play this sort of frustrating game enough that I felt like I had to say something. Also, I feel like any well-functioning community needs to call out behavior like this, which sort of necessitates being a dick. Anyway, I’m sorry, but I had to do it.

Yeah, I found it kind of annoying that the tone was mocking me for not realizing that drug names were important, when my whole point was that drug names *were* important. Sometimes you’ve got to mention the obvious things.

A thing that bugs me more than it probably should is when a pharmaceutical company gets to give a drug both its generic name, and also its brand name, and is therefore able to make the brand name snappy and memorable, and the generic name less so (see, for instance, Prozac vs Fluoxetine), so that people are more likely to continue to ask for the brand name even after the generic is available at a fraction of the cost. It would be nice if things could be set up so that the pharma company gets to decide both names, but someone else gets to then decide which is which.

Drug generic names reflect certain chemical characteristics of the compound and so will necessarily not be snappy. From the names “Mavik” and “Zestril”, or “Tenormin” and “Lopressor”, there is no obvious connection, but the first two are trandolapril and lisinopril, and the latter two atenolol and metoprolol, which makes the connection obvious – each pair shares a mechanism of action.

What bugs me even more is when brand names are completely bland. Take Namenda (memantine). It just seems to me like they put some extra letters in “NMDA”, a receptor memantine acts on. It sounds like trying to say “memantine” with a mouth full of gruel.

I think some official government body gives drugs their generic names.

There’s another government body that has to approve giving drugs their brand name, and which supposedly bans giving them brand names that sound like positive words (eg Supercuredrugium) but this body is apparently either constantly asleep at the wheel or very easy to bribe.

My guess would be in terms of the “several equally effective drugs” scenario, at least one is generic. New drugs only need to prove efficacy versus placebo, not versus older treatments. A company paying a middleman to prescribe a more expensive product, versus a much cheaper but equally effective product, would be called corruption in any other industry.

My wife is an endocrinologist practicing at [Big Academic Hospital] in [Major Midwestern American City]. Being an endocrinologist, about 90% of her patients are diabetic, and the remainder have various other more interesting problems. Most of the diabetics are on insulin pumps and lots of them have absolutely no idea how to use them properly – they can’t set the insulin dose, they can’t change when it’s delivered, etc., etc.

Every few months or so one of the pump manufacturers comes by the hospital and offers to take all the endocrinologists out (attendings, fellows, residents, and interns alike) for dinner so the reps can explain all the new features of their pumps and why these pumps are so awesome. My wife – literally – always attends these sessions. She then talks to the reps and convinces them to loan her a pump and associated bits and proceeds to personally wear the pump for a week or so, giving herself saline injections and testing her blood sugar. Then she gives it back, having learned exactly how this particular pump works.

As a result, when her patients call up in the middle of the night panicked because they can’t get their pump to do what they need, she can walk them through the pump control menus step by step, sight unseen, until it’s working properly again. Her patients love this, and several patients specifically request her because none of the other endocrinologists can do this. Except occasionally one of them will go look up her records in the state’s sunshine laws that disclose whether physicians have taken anything of benefit from pharma reps or medical manufacturers and see that Dr. X has accepted way more benefits than any of the other doctors at the hospital!

What surprisingly broke my PANEXA suspension of disbelief was seeing “gemifbrozil”, “nicitonic acid”, “acetomenaphin”, and “cyclosporine”, and trying to figure out why they only spelled the last one right.

I can imagine fear of FDA/FCC/TLA attention if they put up something that looks like an actual drug ad and mentions actual drugs, but then why leave “cyclosporine” intact? And why worry about writing “nicotinic acid”, which while occasionally called Niaspan, is better known as vitamin B3?

The issue I have with most “Big Pharma are evil drug pushers” arguments is that they are long on evidence that pharma companies spend a lot of money advertising to / schmoozing with doctors, and short on evidence that this actually harms patients in a meaningful way. The second bit is a lot more important, but it’s usually taken as given.

I think successful advertising could change doctor behavior in 3 ways:
1) doctor prescribes drug A instead of equally likely to be good drug B. This is probably fairly common as Scott talks about. But the worst case is that the patient comes back and says “I don’t like how A makes me feel can I try something else?” Or “A isn’t covered by my plan – anything cheaper?” Most docs are pretty responsive to changing prescriptions in this case. I think this is generally harmless.
2) doctor prescribes drug A instead of nothing, when nothing is as good or better than A. This could be bad, but I suspect pressure to prescribe something is a lot higher coming from patients than from pharma reps.
3) doctor prescribes nasty expensive ineffective drug A instead of awesome cheap side-effect free drug B. This is obviously bad, but I’d need to see pretty strong evidence of this before believing otherwise ethical doctors are doing it.

Is there any strong evidence of doctors actually doing 2 or 3 beyond general “advertising works!” research?

And the “pharma buys us lunch to give PowerPoint on new drug” seems to be the most harmless of all (and probably actually a benefit). Sure, the info may be biased, but unless it’s a flat out lie, doctors learning about a new drug is probably a good thing (old doctors probably need more exposure to new research, not less).

Certainly you can lie by omission or bias without strictly telling a falsehood. That’s not my point. The sort of lying typical in a sales presentation is unlikely to significantly harm a patient (maybe it will convince a doctor to prescribe A over B). But assuming the drug is FDA approved and they aren’t “flat out lying”, that is, claiming efficacy that the FDA doesn’t agree with, the negative impacts are small. (Or maybe they aren’t, but my point was I haven’t seen evidence to suggest that, and I don’t think its fair to beg that question)

On the other hand, if a sales presentation exposes a doctor to a drug that is actually a real improvement (these do come out from time to time), that’s a definite net improvement to patient health – they get a new drug that the doctor might not otherwise know is available.

Maybe I’m not well-versed enough in the field, but after reading this it did not seem immediately obvious to me that the bad effects that these pharma companies cause with all this marketing outweigh the good effects. People are getting free lunches, free samples, and so on. Those are definitely good things, does any bias towards specific drugs this imbues the doctors with do enough harm to cancel it out?

The are lots of instances of for-profit corporations providing free goods for advertising purposes that most people agree do more good than harm. The quintessential example is ad-revenue driven websites and TV shows. Pretty much everyone agrees that people being influenced by advertisements is way, way better than “almost no Internet or TV.” Speaking personally, the joy that the 1994 Spider-Man cartoon has brought me over the years is worth far more than the money I spent on the action figures it plugged. I don’t think my younger brother begrudges the Bandai corporation any of the hundreds of dollars he’s spent on model Gundams.

The federal government has gone in the completely opposite direction, as far as what I can see from my mid-level software engineer position.

Contractors bid the government for contracts. So in this case, the contractors are analogous to Big Pharma and the government are the doctors… I assume before the current legal quagmire about how government and contractors interacted, it might have operated in a similar manner to the relationship between doctors and agents of the drug companies: Contractors taking government employees on all expenses paid hotel/dinner splurges, huge ostentatious gifts, etc. all in hopes of getting an edge over other companies who might be bidding on the same contract.

But currently, having a dinner paid for by a potential/current contractor is illegal. It’s even borderline illegal for me to ride in the same car with a contractor if the contractor is driving because it might be seen as the contractor giving me a “gift”.

Headline: “New Study Finds Therapy, Antidepressants Equally Effective At Monetizing Depression” I guess Scott is in a good position to confirm or deny?

More seriously, idea for the day, libertarian/free-market style: (1) Force doctors to publicize, visible to patients and prospective patients, how much of what kind of compensation they get from drug companies, from Jackson Hole right down to a single cookie; then (2) Let patients decide!

Hmm, maybe not a cure-all. But as a patient I would at least like my doctors to be answerable in the sunlight for their baksheesh practices, as a matter of principle and independent of magnitude. Related: I’d also like to have it spelled out for me whether my doctor is getting incentives/kickbacks from my health insurance specifically for prescribing something the insurer prefers, whether it be medications, tests, therapies, or whatever. I’m not saying its a crime, just that I want my doctor’s incentive structure to be clearly made public to the patients. The last time I brought this idea up with a primary doctor all I got were angry looks.

——————-
Lastly, a housekeeping note for Scott: I left a comment on the “About” section, as a kind of faux-e-mail/smoke signal, about a blog thread you might want to attend; it seems that Prof. Scott Aaronson himself has shown up there now, promising a good time all around, check the “About” section comment for details.

Wow, such service! Of course, I looked up my own primary doctor, and apparently he was on the take to the tune of $118 in “Food and Drink” — mostly from AstraZeneca! — through all of 2013, but nothing since then. Which brings up: how accurate should one expect this database service to be? is it required by law to fill it in? and is it the giver or the receiver’s responsibility to do so?

You’re right, Scott. Despite their demanding almost weirdly low qualifications and offering a position doing highly interesting things as a “Machine Learning/Artificial Intelligence Software Engineer”, I think I won’t even try to seek a job doing learning/AI technology for a company that is, at least partially, a defense contractor.

After all, NOTHING HAS EVER GONE WRONG with giving that kind of expertise to the fucking MILITARY.

My one comment on this is that you suggest all antidepressants are basically the same. As someone who had to try 4 or 5 different ones before finding one that worked for me, that seems odd, because they didn’t feel remotely the same. Paxil was very strong for social anxiety, had sexual side-effects, and a certain relaxing effect. Celexa made me feel freaky. Effexor was energizing but in a positive was, and had no sexual side-effects, which is why I ultimately continued to take it.

I’ve also known many people who’ve had trouble with certain antidepressants before finding one that worked better for them. I’m actually very surprised you chose a class of drug I would have called one of the most individualized there is to suggest that they were all the same.

Just one question for you. Given how simplistic, unbalanced, slanted, and ignorant Oliver’s offering was on a subject you know very well, why don’t you assume that every single other commentary he and by extension Jon Stewart have given on subjects you aren’t an expert in was just as simplistic, unbalanced, slanted and ignorant?

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